What does the medical record reveal about functional status? A comparison of medical record and interview data
What does the medical record reveal about functional status? A comparison of medical record and interview data
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DOI：
10.1111/j.1525-1497.2001.00625.x
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发表时间：
2001-11-01
影响因子：
5.7
通讯作者：
Inouye, SK
中科院分区：
文献类型：
--
作者：
Bogardus, ST;Towle, V;Inouye, SK
目的：功能状态测量是医院结局和死亡率的有效独立预测因子。本研究的目的是比较医疗记录与访谈数据的功能status.SUBJECTS和方法：受试者为525名内科患者，年龄在70岁或以上，住院治疗的学术医疗中心。患者访谈确定了7项基本日常生活活动（BADL）和7项工具性日常生活活动（IADL）的状态。医疗记录进行了审查，以评估文件的BADL和IADLs.RESULTS：大多数医疗记录中没有文件的个人BADL和IADL（61%至98%的记录缺乏文件），除了步行（24%的医疗记录缺乏文件）。对于所有BADL和LADL，医疗记录中的损伤患病率低于访谈时，访谈与医疗记录之间的一致性较差（单个BADL和IADL的kappa < 0.40）。以访谈作为参考标准，病历对BADL和IADL损害的敏感性较差（范围为95%至44%）。敏感性和特异性的医疗记录检测BADL和IADL损害的变化时，记录与nondocumentation的功能状态被排除在外，或被假定为相当于independents.CONCLUSIONS：结果表明，医疗记录是一个贫穷的数据来源，许多功能状态的措施，并假设nondocumentation的功能状态相当于独立性可能是没有道理的。考虑到功能状态指标的预后重要性，研究结果强调了开发可靠和有效的手段来获得住院老年患者的功能状态信息的重要性。
OBJECTIVE: Functional status measures are potent independent predictors of hospital outcomes and mortality. The study objective was to compare medical record with interview data for functional status.SUBJECTS AND METHODS: Subjects were 525 medical patients, aged 70 years or older, hospitalized at an academic medical center. Patient interviews determined status for 7 basic activities of daily living (BADLs) and 7 instrumental activities of daily living (IADLs). Medical records were reviewed to assess documentation of BADLs and IADLs.RESULTS: Most medical records contained no documentation of individual BADLs and IADLs (61% to 98% of records lacking documentation), with the exception of walking (24% of medical records lacking documentation). Impairment prevalence was lower in medical records than at interview for all BADLs and LADLs, and agreement between interview and medical record was poor (kappa < 0.40 for individual BADLs and IADLs). Sensitivity of the medical record for BADL and IADL impairment was poor (range 95% to 44%), using the interview as a reference standard. Sensitivity and specificity of the medical record for detection of BADL and IADL impairment changed substantially when records with nondocumentation of functional status were excluded or were assumed to be equivalent to independence.CONCLUSIONS: The results suggest that the medical record is a poor source of data on many functional status measures, and that assuming that nondocumentation of functional status is equivalent to independence may be unwarranted. Given the prognostic importance of functional status measures, the results highlight the importance of developing reliable and efficient means of obtaining functional status information on hospitalized older patients.